Aortic stenosis and the failing heart.
The combination of aortic stenosis and left-ventricular dysfunction is a challenging situation for the physician. Diagnosis of this condition requires a detailed evaluation to understand the etiology and reversibility of the ventricular dysfunction and to accurately determine the real severity of the stenosis. Whether the aortic stenosis the cause of the left ventricular failure or is an independent disease has significant diagnostic, prognostic and therapeutic implications. Dobutamine echocardiography provides critical information to determine the real severity and the left ventricle's potential to recover (contractile reserve). Attempts to delay the progression of the aortic stenosis with medical treatment have been limited, and valve replacement remains the hallmark of ultimate treatment. If surgery is inadvertently delayed, left ventricular systolic dysfunction will result in clinically evident congestive heart failure and this situation carries a very high short-term mortality. Aortic valve replacement in this setting improves the outcome, but perioperative mortality is high, and particularly when coronary revascularization is also needed, there is no ventricular contractile reserve and transvalvular gradients are low. Adequate timing of surgery is extremely important and increasingly more difficult. Management decisions should be tailored by the results of dobutamine echocardiography and made on a case-by-case basis.